Emotional and behavioural changes after brain injury: assessment and support

Emotions and behaviour are closely linked, and after a brain injury some behaviours become more common or hard to control. Headway explains that the frontal and limbic regions that regulate emotion can be damaged, hormonal regulation can be disturbed, and the person also has to live with the consequences of injury, such as lost work, driving and independence. NICE notes that neurological injuries can result in neurobehavioural disturbance, apathy, disinhibition, perseveration, difficulty regulating emotion and abrupt shifts in emotional state known as emotional lability.

These changes are often invisible to others until behaviour shows them, and the person may lack insight, so relatives can be the first to notice. It is worth remembering that many behaviours have triggers, such as noise, heat, interruption, fatigue and poor sleep.

Headway lists depression, anxiety, frustration and anger, feelings of loss, post-traumatic stress disorder, apathy, emotional lability, stress and difficulties with empathy. Depression can become a barrier to accessing support and may involve thoughts of self-harm, in which case speaking to a GP is important. PTSD is described as most commonly following mild injuries, because in more severe injury the circumstances of the event are often not remembered, and some people develop fears related to the early stages of recovery.

Apathy, a loss of interest and motivation, may reflect damage to motivation systems, depression or hopelessness and is often misread as disinterest. Emotional lability involves exaggerated or unpredictable emotion, such as laughing at sad news. Many people report feeling like a new person after injury, which can bring grief for the former self.

Headway describes post-traumatic amnesia, disinhibition, impulsiveness, irritability and aggression, perseveration, egocentricity and personality change. Disinhibition may include crude language, tactless remarks, inappropriate laughter or over-familiarity, and sexual behaviour can be a particular area of difficulty. Impulsiveness may lead to spending without thought for bills. Irritability can escalate to shouting or physical aggression, and the person may not remember or recognise the behaviour afterwards.

If anger becomes violent, abusive or risks harm to the person or others, Headway says intervention through a safeguarding team, domestic abuse services or the police may be needed, and 999 should be called in an emergency. Understanding the injury-related cause does not remove the need for safety.

NICE guideline NG252 says a registered mental health practitioner, for example a psychologist, psychiatrist or mental health nurse, with understanding of the effects of the condition should oversee assessment of emotional health and develop that part of the rehabilitation plan. Assessment should take account of unmet needs elsewhere, because pain, fatigue or poor sleep can drive mood and behaviour.

Headway says clinical neuropsychologists and clinical psychologists with brain injury experience interview the person and family, complete mood screens and recommend coping strategies, talking therapies and lifestyle changes. The GP, neurologist or rehabilitation team can refer and may prescribe medicines where appropriate.

NICE recommends considering CBT, mindfulness-based talking therapy or acceptance-based interventions for low mood, anxiety or difficulty adjusting, and psychoeducation, motivational interviewing and cognitive behavioural approaches when these emotional difficulties are blocking participation in daily activities. Delivery should be adapted, for example using memory or communication aids, changing the number, length and frequency of sessions, and choosing online or face-to-face delivery to suit.

If speaking therapies are difficult because of cognitive or communication problems, creative therapies such as music, art or drama therapy can be considered. For behaviours that challenge, NICE suggests neurobehavioural approaches such as positive behaviour support, which identify triggers, change the environment and teach alternative responses. Individual and group formats are both offered, and people can opt in and out of services as needs fluctuate.

Relatives often find personality change, lack of empathy and apathy harder than physical disability. NICE says families should be involved when agreeing interventions, and Headway offers nurse-led helpline support and local groups. Practical steps include keeping routines steady, reducing noise and demands when someone is tired, agreeing a calm-down plan beforehand, and avoiding arguing about memory or insight in the heat of the moment.

Thoughts of self-harm or suicide need prompt attention. Headway advises contacting a GP, texting SHOUT to 85258, calling the Samaritans or contacting a local NHS urgent mental health helpline, and says to call 999 or go to A&E if there is a need to self-harm or someone has already harmed themselves. If there is immediate danger from aggression, call 999.